Archive for July, 2013

ACO Study Reveals Mixed Results

Wednesday, July 17, 2013 // Uncategorized

Health plans have rushed to form Accountable Care Organizations which are designed to deliver better quality care at lower costs.  There hasn’t been any proof that they were effective in delivering both.   This article from the Wall Street Journal shows that the results are mixed.  Now when they mention better care, this involves adhering to different quality indicators.  Defining quality care is fraught with difficulty.  As I have mentioned in previous posts, these indicators themselves are a source of controversy and a number of indicators have fallen by the wayside in past years.

  • The Wall Street Journal

Mixed Results in Health Pilot Plan

Program Members Raise Quality of Care but Struggle to Lower Costs

    By

  • MELINDA BECK

Lowering health-care costs is tougher than improving the quality of care, according to first-year results from a key pilot program under the federal health law.

All of the 32 health systems in the so-called Pioneer Accountable Care Organization program improved patient care on quality measures such as cancer screenings and controlling blood pressure, according to data to be released Tuesday by the Centers for Medicare and Medicaid Services. But only 18 of the 32 managed to lower costs for the Medicare patients they treated—a major goal of the effort.

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Two hospitals lost money on the program in the first year. Seven have notified CMS that they intend to move to another program where they will face less financial risk. Two others have indicated they intend to leave the program, CMS says, but it declined to identify them.

ACOs are an emerging concept in which hospitals and groups of doctors contract to care for a specified population of patients, with the goal of improving quality and lowering costs by better coordinating care. In general, ACOs are shifting to a system that pays doctors to keep people healthy, as opposed to the volume of services they provide. To do this, many systems emphasize preventive care to stave off costly hospitalizations.

The pilot program is a closely watched first indicator of whether these pillars of the landmark federal health law can help transform care. However, some analysts said it is unsurprising that more participants didn’t achieve savings in the first year, given that the program has three years to achieve its goals.

As outlined in the Affordable Care Act, health systems that lower the cost of care for a large group of Medicare beneficiaries, while meeting 33 quality measures, stand to split the savings with Medicare. The systems chosen as Pioneers were supposed to serve as models, since they were already experienced in providing such value-based care.

The Obama administration says it is pleased with the results on quality measures. “Overall, we are very excited about the results. It’s incredibly rare that 100% of the participants outperform benchmarks,” said Patrick Conway, chief medical officer for CMS and acting director of its Innovation Center, which runs the program.

The Pioneers were able to slow cost increases, according to the initial indicators. On average, costs for the more than 669,000 Medicare beneficiaries treated in the 32 Pioneers grew by only 0.3% in 2012, compared with 0.8% growth for typical Medicare beneficiaries, CMS said.

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The ACO concept has spread quickly. Another 250 health-care systems have set them up under Medicare’s Shared Savings Program, which is similar except that those ACOs aren’t required to share in any losses, as Pioneers are. They stand to share only in the savings in the first two years.

Commercial insurance companies have set up nearly 200 ACO-type contracts with health-care systems. Last week, UnitedHealth Group Inc.   UNH -1.02% said it expects to double its accountable-care contracts to $50 billion by 2017. More than a dozen states also have created ACOs to care for Medicaid patients.

As of January 2013, the Shared Savings ACOs were providing care for more than four million Medicare beneficiaries in 49 states, according to Leavitt Partners LLC, a health-care consulting firm.

Of the 18 Pioneers that saved money, 13 saved enough to be able to split their savings with Medicare, generating a gross savings of $87.6 million in 2012. Among them was Partners Healthcare in Boston, which includes Massachusetts General.

“We did great. We saved about $14.4 million for Medicare, and will get back a little over $7 million,” said President and Chief Executive Gary Gottlieb.

He said that about 70% of the system’s patients are still under traditional “fee-for-service” contracts, where a hospital is paid separately for the individual services it provides. However, on the basis of the pilot-program results, he said he expects to move toward the ACO model “as we continue to demonstrate cost savings and quality improvements.”

Bellin-ThedaCare Healthcare Partners in northern Wisconsin lowered costs for its 20,000 Medicare ACO patients by an average of 4.6% compared with the baseline population the program used for comparison. It stands to share in several million dollars in savings.

Executive Director David Krueger said the health-care system reduced hospital admissions rates, readmission rates and length of hospital stays for its ACO patients. “All that would be very bad news in a fee-for-service world, but in a shared-savings world, it’s very positive news,” he said.

One of the two that incurred losses was Atrius Health, a nonprofit alliance in eastern and central Massachusetts. Officials there said one difficulty Atrius faced was that the historical cost-per-patient it needed to beat was already unusually low, because they had lowered costs in years before. “We didn’t have as much low-hanging fruit,” said Emily Brower, executive director of the ACO.

Getty ImagesPresident Obama speaks about Affordable Care Act at the Fairmont Hotel on June 6 in San Jose, Calif.

She said Atrius may owe Medicare about $2 million, but the total amount won’t be known until the next quarter. But she said the system has no plans to leave the program.

Many health-care analysts said they weren’t surprised that more Pioneers didn’t achieve savings—in part because many of their other patients are still under traditional payment contracts. “It’s like being a little bit pregnant,” said Chas Roades, chief research officer of the Advisory Board Co., which advises hospital systems. “It’s hard to manage two separate sets of books, and it’s hard to ask doctors to practice medicine in two different ways.”

When organizations undertake major health-care reforms, “it’s a marathon, not a sprint,” said Mark McClellan, former administrator of CMS who now directs the Engelberg Center for Health Care Reform at the Brookings Institution, a left-leaning Washington think tank. Significantly lowering the cost of care is harder and takes more time than showing improvements in quality.

“It’s a big step just to be able to track which of your patients has diabetes, let alone improving their care at less cost,” he said.

Write to                 Melinda Beck at [email protected]

Corrections & Amplifications                                 The name of health-care consulting firm Leavitt Partners LLC was misspelled as Levitt in an earlier version of this article.

A version of this article appeared July 16, 2013, on page A1 in the U.S. edition of The Wall Street Journal, with the headline: Mixed Results In Health Pilot Plan.

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ADD/ADHD Drugs and And Grades

Wednesday, July 10, 2013 // Uncategorized

Millions of kids and adults take drugs for attention deficit disorder.  It is not at all clear whether these drugs improve academic performance.  This article would suggest that they don’t.  Many people without ADD or ADHD the drugs to improve academic performance without evidence that they are effective.

  • The Wall Street Journal
  • IN THE LAB
  • Updated July 8, 2013, 8:35 p.m. ET

ADHD Drugs Don’t Boost Kids’ Grades

Studies of Children With Attention-Deficit Hyperactivity Disorder Find Little Change

 

 

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It’s no longer shocking to hear of children with attention-deficit hyperactivity disorder—and others simply facing a big test—taking ADHD medicine to boost their performance in school. But new studies point to a problem: There’s little evidence that the drugs actually improve academic outcomes.

Stimulants used to treat ADHD like Ritalin and Adderall are sometimes called “cognitive enhancers” because they have been shown in a number of studies to improve attention, concentration and even certain types of memory in the short-term. Similar drugs were given to World War II soldiers to improve their ability to stay alert while scanning radars for enemy aircraft.

However, a growing body of research finds that in the long run, achievement scores, grade-point averages or the likelihood of repeating a grade generally aren’t any different in kids with ADHD who take medication compared with those who don’t. (Typically, studies take into account accommodations schools provide kids with ADHD, such as more time to take tests.)

University of PennsylvaniaDr. Martha Farah and colleagues found no cognitive benefit from Adderall taken by students.

A June study looked at medication usage and educational outcomes of nearly 4,000 students in Quebec over an average of 11 years and found that boys who took ADHD drugs actually performed worse in school than those with a similar number of symptoms who didn’t. Girls taking the medicine reported more emotional problems, according to a working paper published on the website of the National Bureau of Economic Research, a nonprofit economics research firm.

“The possibility that [medication] won’t help them [in school] needs to be acknowledged and needs to be closely monitored,” says economics professor Janet Currie, an author on the paper and director of the Center for Health & Wellbeing, a health policy institute at Princeton University. Kids may not get the right dose to see sustained benefits, or they may stop taking the medication because side effects or other drawbacks outweigh the benefits, she says.

A central question puzzles those researching ADHD: If its drugs demonstrably improve attention, focus and self-control, why wouldn’t grades improve as well?

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Millions of children and college students take medication to treat ADHD and to help them perform better in school. But there isn’t great evidence to suggest that these drugs actually improve academic outcomes. Shirley Wang reports on the News Hub.

 

Scientists are trying to understand this paradox in hopes of being better able to treat ADHD, a condition characterized by difficulty with attention and emotional control. Many kids are diagnosed when they start having trouble in school and are put on medication, often to help improve their odds of succeeding academically and socially.

According to the Centers for Disease Control and Prevention, some 2.7 million kids were taking medication for ADHD in the U.S. as of 2007, the most recent data available. Some experts estimate that 15% to 20% of all ADHD medicine in the U.S. is diverted or shared with people who don’t have a prescription. Whether the drugs help the academic performance of kids without the disorder is even less clear.

“I don’t think that at this point we have any clear evidence that stimulants can enhance cognition in non-ADHD individuals,” says James Swanson, a professor emeritus at the University of California, Irvine, who studies this issue with colleagues at Florida International University.

The lack of academic benefit has been surprising because the drugs seem to have the potential to improve memory, among other cognitive skills. For instance, Claire Advokat, a professor emerita in the psychology department at Louisiana State University, and her colleagues found in a small study that episodic memory—memory for experiences—improved when kids with ADHD took relevant medication.

Children with ADHD not taking stimulants did far worse than kids taking medication in tasks that involved remembering scenes from a story they both heard and saw illustrated. Kids taking medication did just as well as control children without ADHD, according to the study published in April in the journal Pharmacology Biochemistry and Behavior.

But the effects largely don’t seem to translate into the classroom, especially in the long run. In one major, U.S. government-funded study known as the MTA that looked at the long-term effects of ADHD treatment, 579 children with the condition were randomized to one of three different kinds of treatment or a control group for 14 months.

For the first year of the study, the 8- and 9-year-old children who received medication and a combination treatment saw greater improvements in ADHD symptoms than the other two groups. Kids taking medicine also exhibited some improvement in educational outcomes in that first year.

But any benefit of the drug on symptoms dissipated by Year Three. At the most recent set of assessments, the eight-year follow-up, there were no differences between any of the groups on symptoms or academic achievement measures, suggesting that there wasn’t any long-term residual benefit of the treatments during childhood.

One way of interpreting the findings is that the medicine proves effective on immediate classroom behaviors like sitting still and interrupting the teacher less, but it doesn’t help with other factors important to successful completion of homework or test-taking, like family encouragement.

Other studies have shown that kids who take ADHD medication and study early for an exam tend to do just as well, if not better, than kids without ADHD. But those who take medication and study at the last minute don’t do any better.

Together, these findings suggest that medication alone isn’t enough to improve academic performance. The medicine may help with focus, but it doesn’t help with deciding what to focus on, experts say. Rather, it needs to be coupled with skills training, such as learning how to organize or prioritize.

The medication’s ability to improve concentration and attention may even backfire when it comes to studying.

Martha Farah, a cognitive neuroscientist at the University of Pennsylvania who sits on the American Academy of Neurology committee that is drafting new treatment guidelines, recalls a student saying that after she takes her medication, she heads to the library. If she keeps her head down and studies, she gets very absorbed in her work and accomplishes a tremendous amount. But if a friend stops by, she becomes equally engrossed in the chat. Many students report they find themselves absorbed in cleaning their rooms rather than studying.

In people without ADHD, there is even less information about whether stimulants lead to any real academic benefit.

Dr. Farah, who is also head of the Center of Neuroscience & Society, and her colleagues found no significant cognitive benefit from Adderall in students assessed on a number of psychological tests, including neurocognitive performance and I.Q. tests. The paper was published in Neuropharmacology in January.

In a separate study, a statistical review of existing data on the topic, still unpublished, suggests there are “very small effects—not zero but not a whole heck of a lot difference,” Dr. Farah says.

Write to                 Shirley S. Wang at                 [email protected]

A version of this article appeared July 9, 2013, on page D1 in the U.S. edition of The Wall Street Journal, with the headline: ADHD Drugs Don’t Boost Kids’ Grades, Studies Find.

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